Subtypes of Alcoholics Based on Psychometric Measures.

One approach to subtyping alcoholics is the use of psychometric tests that quantify a person's personality characteristics, psychological characteristics, and intelligence. For example, researchers have used the Personality Research Form, which measures basic personality traits, to establish alcoholism typologies. Other psychometric measures that have been employed in the classification of alcoholics, such as the Minnesota Multiphasic Personality Inventory and the Millon Clinical Multiaxial Inventory, measure the presence of co-occurring psychiatric disorders in the patients. Still other subtypes are based on tests assessing the patient's motivation for treatment. Although clinicians hope to use psychometric typologies to improve treatment planning and monitoring for their patients, several questions remain to be answered by additional research before the instruments and the typologies based on them achieve broad applicability.

A lcoholics differ significantly with • The measure used to assign patients teristics, psychological characteristics, respect to their personality to subtypes is easy to administer or intelligence. These instruments, types, their patterns of alcohol and evaluate. which usually are questionnaires, have consumption, and the kind and severity several advantages over more subjec • The vast majority of patients can of their drinking problems. Similarly, a tive assessment strategies, such as clin be classified into a relatively small wide variety of interventions exist for number of distinct subtypes. ical interviews. For most psychometric treating alcoholism. A major goal of tests, researchers already have deter • The subtyping measure can be ad mined their validity (i.e., that the tests contemporary alcoholism research is to ministered early during the course actually measure the characteristics develop decision rules allowing treat of treatment so that the most appro they are supposed to measure) and ment providers to assign patients to priate intervention(s) can be selected. reliability (i.e., that the results are specific interventions that are most reproducible). Furthermore, existing effective for them. Because it is not • The typology allows treatment pro standards show how the results of a feasible to design a personalized treat viders to select the appropriate treat given patient differ from his or her ment program for each alcoholic, a pre ment approach available within their programs or to suggest appropriate peers. Psychometric measures also requisite for such decision rules is the referral options for needed services can evaluate domains of interest (e.g., identification of subtypes of alcoholics not available within the programs. the presence of certain personality that share common characteristics. characteristics) with greater compre Researchers have pursued many • The results of the subtyping meas hensiveness and less bias than other different approaches to developing al ure provide feedback to the patients assessment tools. Finally, these tests coholism typologies (for more infor and enhance their motivation for tend to be more economical, because treatment. mation, see the article by Babor,. To  their completion by the patient does not require the presence of a clinician, and many appropriate instruments either are not copyrighted or may be used after paying only a small royalty. This article reviews systems for sub typing alcoholics in treatment based on cluster analyses 1 of psychometric tests that assess the alcoholic's personality traits, psychopathology, or treatment motivation. Most of these typologies are based on a relatively small number of tests, including the Personality Re search Form (PRF), the Minnesota Multiphasic Personality Inventory (MMPI), and the Millon Clinical Mul tiaxial Inventory (MCMI), which are discussed below. However, other as sessment measures (e.g., the Alcohol Use Inventory [Donat 1994], the Michigan Alcoholism Screening Test [Snowden et al. 1986], and cognitive neuropsychological measures [Donovan et al. 1986]) have been used occasion ally. This article also highlights some of the questions that must be addressed before the clinical utility of these psy chometric measures and typologies can be determined unequivocally.

PERSONALITYBASED TYPOLOGIES
Approaches to classifying alcoholics according to their personality charac teristics (e.g., impulsivity and emotion ality) are based on the assumption that such characteristics could influ ence both the risk for and the treat ment of alcohol and other drug (AOD) abuse. One of the most technically sophisticated and highly researched measures of basic personality traits is the PRF (Jackson 1984). This test as sesses 20 common human needs, such as achievement and social recognition, rather than characteristics that reflect major emotional problems, such as de pression or schizophrenia. The test has been used extensively to determine risk factors for AOD abuse and personality 1 Cluster analysis is a statistical technique that groups individuals into a small number of subtypes based on similarities of members' scores on several variables. The technique also attempts to establish subtypes that differ considerably from one another. characteristics associated with the treatment process .
Several researchers have used the PRF to develop typologies of alco holics in treatment (Nerviano 1976(Nerviano , 1981Zivich 1981). Although the sample characteristics and specific PRF versions used differed slightly across these studies, their results seem largely consistent. In all three studies, the investigators identified several sub types that differed not only in their characteristics according to the PRF but also with respect to characteristics assessed by other psychometric instru ments (e.g., the MMPI). The relevance of these studies, however, is somewhat limited because they included only male alcoholics. Furthermore, the researchers could assign only approx imately 50 percent of the subjects un ambiguously to any of the subtypes, a percentage lower than that of most other subtyping systems.
The PRF also served as the basis for alcoholism subtypes in an investi gation by Allen and colleagues (1994) that included both male and female AODdependent inpatients. The re searchers distinguished five subtypes, which encompassed almost all the subjects. The gender composition, how ever, varied significantly among the subtypes. As in the earlier studies, the subtypes differed not only in the char acteristics assessed by the PRF but also in two independent MMPI meas ures related to the expression of im pulses and emotionality. Moreover, subtype membership correlated with the likelihood that certain internal and external stimuli prompted AOD use. The researchers proposed that differ ences among the subtypes regarding measures of psychopathology and stim uli for AOD abuse could have impli cations for the most effective type of intervention for each subtype. The actual value of this theoretical "patient treatment matching" approach, how ever, has not yet been determined.

PSYCHOPATHOLOGYBASED TYPOLOGIES
High rates of cooccurring psychiatric disorders (e.g., antisocial personality Type I/type A alcoholism illustrated in "Les joueurs de cartes," 1890-1895, by Paul Cé za nne . R eprod uc ed w it h perm is sio n from the Musée du Jeu de Paume. © des Musées Nationaux, Agence Photo RMN. disorder, depression, and schizophre nia) among patients in alcoholism treatment suggest that meaningful subtypes could be defined based on the presence or absence of these dis orders. Two psychometric instruments, the MMPI and the MCMI, have proven especially valuable in this regard.

Typologies Based on the MMPI
The MMPI is by far the most frequently used psychometric measure for devel oping typologies of alcoholics in treat ment. This test, which consists of 550 questions, is used frequently to deter mine personality characteristics and to diagnose various psychopathological disorders. The MMPI questions can be grouped into different scales, or sets of questions that focus on specific aspects of personality or psychopathology (e.g., impulsivity or depression). When in terpreting the test results, clinicians focus primarily on the pattern of scales on which a patient scores highest, rather than on the specific scores on each scale. Accordingly, a test result is ex pressed as a profile code (e.g., 2-8-7-4) according to the scales on which the patient exhibited the highest scores. (For more information on the MMPI, see the article by Ingle, Several studies have resulted in typologies based on MMPI test per formance (e.g., Graham and Strenger 1988;Morey et al. 1987). Although these studies generally differed in the number and characteristics of subtypes, they consistently identified at least one alcoholic subtype with prominently el evated scores on scale 4, a scale meas uring psychopathy. These elevated scale 4 scores declined only slightly and remained above normal during alcohol ism treatment (Graham and Strenger 1988). The significance of this scale for evaluating alcoholics is underscored by findings that elevated scale 4 scores also could predict future alcohol prob lems in young male college students long before they were likely to suffer from alcohol problems or enter alcohol ism treatment (Kammeier et al. 1973).
Several researchers attempted to consolidate the various MMPIbased typologies reported in the literature by comparing subtypes described across a wide range of studies. As a result of such analyses, Graham and Strenger (1988) suggested that six reproducible subtypes of alcoholics existed, which differed on several personality, psycho pathological, drinking, and treatment related variables. In contrast, Morey and colleagues (1987) postulated only three subtypes (i.e., early stage problem drinkers, affiliative alcoholics, and schizoid alcoholics 2 ) in an MMPI based typology. These three subtypes originally had been identified in the re searchers' "hybrid model" (described later) and were based primarily on the Alcohol Use Inventory 3 (Morey et al. 1984). The researchers found that of the 79 MMPI subtype profiles from 11 studies analyzed, 91 percent corre lated significantly with 1 or more of the 3 subtypes. All three subtypes were characterized by a 2-8-7-4 MMPI pro file code, indicating elevated scores on scales that reflect high degrees of depression, alienation from others, unusual thought patterns, anxiety, and impulsivity. Differences between the subtypes existed mainly in the degree of elevation on these scales.
To assess the usefulness of MMPI based typologies in determining ade quate treatment for alcoholics and in evaluating treatment results, researchers also examined the stability of MMPI scores during the course of alcoholism treatment. These studies found that over 30 days of treatment, the overall 2 These subtypes are described in more detail on p. 27. 3 The Alcohol Use Inventory is a selfadministered test that assesses drinking behavior and frequently is used in treatment planning. elevation of clinical scales tended to decline and the profiles became less distinctive (e.g., Dush and Keen 1995;Sheppard et al. 1988). Moreover, some subjects fell into a different subtype after repeated testing. These findings suggest that not only is MMPIbased subtyping helpful in initial treatment planning but that repeating the test during treatment could assist in plan ning later treatment stages. Alterna tively, the changes in MMPI scores and subtype affiliation could indicate that MMPI scores determined during withdrawal bear little relation to the person's MMPI scores before the on set of alcoholism, which would be more relevant for treatment. Both of these interpretations suggest, however, that MMPI testing probably should be delayed until the patient's condition has stabilized after detoxification.

Typologies Based on the MCMI
The MCMI (Millon 1983) is a 175 item survey that assesses the psycho logical characteristics of psychiatric patients. The test has 20 scales that evaluate the patients with respect to 8 basic personality styles (e.g., how the subjects relate with other people), 3 severe personality disorders, and 9 classes of acute symptoms of emo tional difficulties.
Four studies defined subtypes of AODabusing patients based on MCMI analyses (Bartsch and Hoffman 1985;Donat 1988;Mayer and Scott 1988;Donat et al. 1991). The results of these studies were as follows (the studies did not actually label the subtypes but de scribed them based on MCMI scales most distinctive for each subtype): • Bartsch and Hoffman (1985) iden tified five subtypes among a sam ple of male Veterans Affairs (VA) clients in inpatient alcohol ism treatment.
• Donat (1988) distinguished five subtypes in a sample including both women and men. These sub types appear to correspond to those proposed by Bartsch and Hoffman (1985) based on a com parison of the patterns of MCMI scales with high scores between the two studies. Gender had only a minor effect on subtype mem bership: Although women were overrepresented in one category and underrepresented in another, these two subtypes had similar profiles of MCMI characteristics.
• Mayer and Scott (1988) assessed male, alcoholic VA inpatients using only the MCMI scales per taining to personality styles and severe personality disorders. The patients fell into four subtypes that differed primarily with re spect to psychological difficulties (e.g., hallucinations, suicide at tempts, and psychiatric hospital izations). Pairs of subtypes also differed on several drinkingrelated variables, such as age of onset of alcohol abuse, presence of with drawal seizures, and likelihood of completing treatment. Three of the subtypes corresponded to those identified by Bartsch and Hoffman (1985), and the fourth subtype was moderately related to one of the remaining two subtypes.
• Donat and colleagues (1991) also divided their male and female sub jects into five subtypes. These cat egories differed on several scales of the Alcohol Use Inventory that pertained to perceived benefits of drinking, problems resulting from drinking, and-to a lesser extentstyle of drinking (e.g., drinking alone or with others). The re searchers also compared the mean scores on the MCMI scales for their five subtypes and those pro posed by Bartsch and Hoffman (1985) and Mayer and Scott (1988). These analyses indicated a high degree of correspondence be tween the subtypes derived from all three studies.

SUBTYPING BASED ON MOTIVATION FOR TREATMENT
The effectiveness of interventions dur ing alcoholism treatment may depend on the patients' motivation for treat ment. For example, people who do not realize that they have an alcohol prob lem might do better with interventions designed to help them acknowledge the need for change. In contrast, alco holics who already are aware of their problem may respond better to treat ment focusing on how to make person al changes. Consequently, subtyping patients based on their readiness to change may have considerable clini cal value. The University of Rhode Island Change Assessment Scale (URICA) (McConnaughy et al. 1983) is a popu lar approach to evaluating patient mo tivation. Although this scale has been used predominantly in research on smoking cessation, it also recently has been employed in alcoholism treatment studies. The URICA is a brief self report measure that scores patients on four scales representing stages of mo tivation for change (Prochaska and DiClemente 1986): (1) precontempla tion (i.e., unawareness of the need to change one's drinking behavior), (2) contemplation (i.e., acknowledging the problem and seriously considering necessary changes), (3) action (i.e., engaging in concrete efforts to change and seeking assistance), and (4) main tenance (i.e., attempting to consolidate and sustain positive gains achieved). Although most patients fall primarily into one category in this change proc ess, they may display behaviors and express attitudes associated with an additional-usually adjacent-stage.
Two studies examined a large num ber of patients entering treatment for AOD abuse with respect to their URICA stage patterns (DiClemente and Hughes 1990; Carney and Kivlahan 1995). Although their samples differed in age, gender, diagnosis, and employ ment patterns, both studies identified four similar subtypes that they labeled precontemplation, contemplation, par ticipation, and ambivalent. Subjects of the precontemplation subtype had high scores on the URICA precontemplation scale and low scores on the contempla tion scale. The contemplation subtype had high scores on the contemplation scale and low scores on both the pre contemplation and action scales. Fi nally, the ambivalent subtype, like the precontemplation subtype, scored high on the precontemplation scale but also had moderate scores on the scales representing the other three stages of change. In addition, DiClemente and Hughes (1990) identified a subtype they labeled as uninvolved or discour aged, which included patients with low scores on all URICA scales. Patients in the various subtypes differed with respect to the perceived benefits, styles, consequences, and concerns related to drinking; the perceived ability to change their own behavior; and the extent to which they were tempted to drink.
An alternative measure of treatment motivation is the Stages of Change Readiness and Treatment Eagerness Scale (Miller 1992). In one study, clus ter analysis of the outcome of male, AODabusing VA inpatients using this scale indicated that the patients fell into three subtypes labeled ambiva lent, uninvolved, and active (Isenhart 1994). Seventy percent of the subjects in this study belonged to the active subtype. The greatest differences pre dictably existed between the uninvolved and active subtypes. Compared with members of the uninvolved subtype, members of the active subtype exhib ited higher levels of alcohol use, in volvement with and dependence on alcohol, loss of control over drinking, and awareness of adverse consequences of drinking. The three subtypes, how ever, did not differ in their MMPI profiles or with respect to sociodemo graphic factors.

THE HYBRID MODEL FOR CLASSIFYING ALCOHOLISM
Most alcoholism typologies based on psychometric measures assess only one domain (e.g., personality, psy chopathology, or treatment motivation). Some researchers, however, have at tempted to classify alcoholics simulta neously by the type and severity of their problems and by multiple under lying patient characteristics. The best elaborated of these schemes was de veloped by Morey and colleagues (1984), who distinguished three sub types of alcoholics based primarily on subscale scores of the Alcohol Use Inventory. These subtypes-which included early stage problem drinkers, affiliative alcoholics, and schizoid alcoholics-differed on several dimen sions, including personality traits (as assessed by the PRF), intellectual func tioning, demographics, psychopathol ogy, and alcohol use, as follows: • Early stage problem drinkers re ported later onset of drinking, drank less per day, and suffered fewer adverse consequences due to drinking than members of the other subtypes. In addition, the early stage problem drinkers dif fered from patients in the other subtypes by exhibiting higher needs for achievement and abstract thinking as well as reduced levels of aggressiveness and impulsivity.
Overall, these patients' character istics were relatively close to the norms established in the PRF.
• Affiliative alcoholics tended to drink more continuously than early stage problem drinkers. In addition, compared with the other subtypes, the affiliative alcoholics also were more likely to drink with others, were more heavily influ enced by peers, and reported more interpersonal difficulties.
• Schizoid alcoholics revealed the most severe drinking problems and drinking consequences and frequently suffered from anxiety and feelings of guilt. In contrast to the affiliative alcoholics, they typically drank alone and tended to engage in binge drinking rather than continuous drinking. Compared with the other two subtypes, schizoid alcoholics had higher PRF scores indicative of aggression and impulsivity and lower scores on traits of affilia tion and understanding.
Proponents of the hybrid model have attempted to correlate these three subtypes with other existing alcohol typologies. These analyses indicated that the affiliative alcoholic subtype had some similarities with Jellinek's delta alcoholism (Morey and Skinner 1986), Cloninger's type I alcoholics 4 (Morey and Jones 1992), and Babor's type A variant of alcoholism (Babor et al. 1992). Conversely, the schizoid alcoholic subtype resembled Jellinek's gamma alcoholism (Morey and Skinner 1986), Cloninger's type II alcoholism (Morey and Jones 1992), and Babor's type B variant (Babor et al. 1992). (For more information on the typologies of Jellinek, Cloninger, and Babor, see the article by Babor,

USEFULNESS OF PSYCHOMETRIC TYPOLOGIES FOR TREATMENT PLANNING
As mentioned previously, to provide meaningful implications for treatment planning, typologies should meet at least five requirements. All the psy chometric instruments and typologies discussed here satisfy at least two of these criteria: (1) they are relatively easy to administer and (2) they classify the majority of patients into a limited number of subtypes. However, research has not yet adequately addressed whether these psychometric tests can be administered and reliably evaluated early in treatment. Clinicians generally delay testing until patients have stabi lized, often 7 to 10 days after entering treatment. To date, no clinical studies have determined the degree of cognitive and emotional stabilization required for the results of various classes of per sonality tests to be considered valid.
Similarly, no published studies have rigorously examined how the various subtypes described by psychometric typologies respond to different treat ment alternatives and whether such typologies lead to more effective assignment of patients to treatment. Many reports on subtypes offer treat ment recommendations, and general research on enhancing treatment out come by matching patients to inter ventions based on particular needs has yielded positive results . The extent to which psy chometrically based typologies actu 4 In contrast to Cloninger's typology, however, both the affiliative and schizoid alcoholics exhibit an early onset of drinking problems and do not differ in their gender composition or in their family history of alcoholism. ally improve clinicians' abilities to plan alcoholism treatment, however, has not been determined.
With respect to satisfying the re quirement that the results of subtyping enhance the patient's motivation for treatment, alcoholspecific typologies (e.g., the hybrid model) probably are more effective than systems based on general personality characteristics or cooccurring psychopathology. The latter two domains are likely more dif ficult to change through treatment or patient choice than are drinking patterns or the motivation for rehabilitation.

NEEDS FOR FURTHER RESEARCH
Although extensive research has ex amined the use of psychometric in struments to classify alcoholic patients into specific subtypes, several salient questions remain to be answered.
First, and most important, re searchers must evaluate the applied value of alcoholism typologies. This includes determining the extent to which assigning patients to treatment interventions based on subtype im proves outcome, compared with random assignment or assignment according to other systems, such as patient gender, severity of the pa tient's problems, or practical conve nience of the intervention.
Second, little research has evaluated similarities of psychometric typolo gies using the same test across studies or employing different tests within studies. Although the visual appear ance of psychometric profiles or verbal descriptions of subtypes may appear similar in different studies, the actual congruence between subtypes must be determined through statistical analy ses (Bohn and Meyer 1994). Unfor tunately, this has rarely been done.
Third, researchers should evaluate the potential of additional psychometric measures for classifying alcoholics in treatment. The prospects for deriving useful alcoholism typologies from such tests depend on both the relationship of patient variables to available treat ment choices and on the tests' accura cy in assessing these variables. Tests failing to measure treatmentrelevant variables accurately are unlikely to yield workable typologies. Several measures exist, however, that may have strong implications for alcohol ism treatment planning and thus could prove useful for classifying alcoholics. These include the Alcohol Expectancy Questionnaire (Brown et al. 1987) and the Inventory of Drinking Situations (Annis 1982) as well as robust measures of broad personality characteristics, such as the Neuroticism Extraversion and Openness Personality Inventory (NEO) (Briggs 1992). To date, these instruments have not yet been used to develop alcoholism typologies.
Fourth, the possible influence of gender on subtyping should be ex plored in more detail. Although some of the studies mentioned here have ob served differences in the gender compo sition of certain subtypes, the potential effects of gender on the fundamental structure of a psychometrically based typology have not been studied. Such studies would require researchers to develop separate typologies for male and female samples and compare the resulting classification systems. Simi larly, little is known about psychometric typologies of adolescents entering alco holism treatment (Massey et al. 1992).
Fifth, investigators have not yet addressed the correlation between the choice of typology instruments used in a given treatment program and the treatment options available in that pro gram. It seems reasonable to assume that for optimal treatment results, the psychometric instrument chosen in a facility would be related to the range of available treatment possibilities. For example, instruments and typologies based on measures of psychopathology would be expected to be most helpful in programs equipped to treat patients with cooccurring psychiatric disorders. Similarly, typologies reflecting the pa tient's readiness for change might prove most useful in behaviorally focused treatment programs with components available to enhance or sustain treat ment motivation.
Finally, it would be of interest to compare typologies of alcoholic pa tients with those of matched patients with other behavioral or psychiatric problems or of healthy people using the same psychometric measure. Such comparisons could increase our knowl edge of the effects of alcohol prob lems on other basic dimensions of functioning and enhance our under standing of alcoholic patients' treat ment needs by comparing them with other clinical populations.

OUTLOOK ON TREATMENT PLANNING
One of the potential benefits of devel oping typologies is to allow treatment providers to quickly and easily assign alcoholics to patient groups with simi lar treatment needs. So far, researchers do not know whether-and to what extent-existing psychometric typolo gies have achieved this goal. In addi tion, treatment providers can base their treatment decisions on alternative measures, such as nontestbased ty pologies, many of which are described elsewhere in this journal issue, there by further confounding the relevance of psychometric typologies. Another treatmentplanning strategy could in volve a "menudriven" approach in which patients are assigned to a variety of specific treatment modules related to their individual needs beyond those indicated by their alcoholism subtype affiliation. Furthermore, researchers in the future may develop a particu larly potent medication or behavioral intervention that can benefit all alco holic patients regardless of their sub type. Thus, although typologies based on psychometric measures offer intrigu ing suggestions for more effectively determining the needs of alcoholics in treatment, only wellcontrolled research can demonstrate the value of these and other strategies in improving the treatment outcome of alcoholics. ■